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ADVANCE Perspective: Physical Therapy & Rehab Medicine

CMS Scrutinizes Joint Replacement Outcomes
by Jon Bassett
Some would say it was a matter of inevitability. Others will hail its arrival as a much-needed shift away from pay-per-procedure and toward pay-for-quality.

On April 1, 2016, CMS began the testing phase of its Comprehensive Care for Joint Replacement (CJR) model, a new payment structure for episodes of care related to total knee and total hip replacements under Medicare.

According to CMS, Medicare beneficiaries received more than 400,000 knee and hip replacement surgeries in 2014. While these procedures enjoy massive appeal because of their ability to improve overall quality of life, complications and costs vary significantly.

The CJR testing phase is planned to last five years and will be implemented in 67 metropolitan statistical areas, including almost 800 hospitals.

One such region is the New York Metropolitan area, which includes Northwell Health, consisting of 21 hospitals and nearly 450 outpatient practices. Fourteen of its hospitals will participate in the CJR pilot project, becoming responsible for both the cost and overall quality of care delivered to Medicare patients for 90 days after their procedures.

"The discharge from the hospital is not the end of the medical journey for the patient, but marks the beginning of the next phase of recovery," remarked Zenobia Brown, MD, MPH, medical director at Northwell Health Solutions.

CMS is billing the CJR pilot project as a departure from the traditional "fee-for-service" model of care, in which providers are paid whenever they treat a patient. The bundled payment system holds hospitals accountable for all costs incurred during the entire episode of a patient's care -- from admission, to surgery, inpatient hospital stay, rehabilitation, and other care delivered after the patient leaves the hospital. 

Study Shows Benefits of PT for Obese COPD Patients
by Katherine Bortz

A new study has surfaced displaying the benefits of physical therapy for obese patients hospitalized with Chronic Obstructive Pulmonary Disease (COPD).

Researchers at the University of Granada and Virgen de las Nieves Hospital, both located in Spain, have seen results that suggest less hospitalization for those suffering with the disease. Their results show that a short-term physical therapy regimen leads to a better quality of life for the patient and is more cost effective for the hospital. Forty-nine patients were selected to receive multimodal therapeutic care. The regimen was carried through for seven to 10 days. The project was funded by the Health and Progress Foundation, Boeghringer Inghelheim and Oximesa.

The exercises mostly focused on the lower extremities, included work with elastic bands, pedaling and activities where patients were seated. Patients also were given routines where balancing on one foot was required. The researchers concluded that there were beneficial effects of physical functioning in hospitalized obese patients with acute exacerbation COPD.

This research is published in “COPD: Journal of Chronic Obstructive Pulmonary Disease.”

COPD is a chronic inflammatory lung disease where airflow from the lungs is obstructed. According to Mayo Clinic, symptoms include: breathing difficulty, cough, sputum production and wheezing. In many cases, COPD is developed by smokers or those who have had long-term exposure to irritating gases or particulate matter.

How do you think that physical therapists can help improve the lives of those hospitalized with chronic conditions, including COPD?

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New Guideline Promotes PT for Chronic Pain
by Katherine Bortz
Chronic pain is becoming a worsening problem in America, with 14.6% of the population living with symptoms daily. Currently, the first line of defense against the condition is through the prescription of opioids such as transdermal fentanyl, and extended-release versions of opioids such as oxycodone, oxymorphone, hydrocodone and morphine. While they do alleviate symptoms of the condition, they also have an increased chance for misuse or addiction. Many are beginning to wonder if this is really the best way to go about treating patients.

The CDC recently published its guideline for prescribing opioids and urged healthcare professionals to weigh the benefits of certain therapies with the risks. In this guideline, a conclusion was reached that non-opioid and non-drug options like physical therapy, weight loss for knee osteoarthritis, psychological therapies such as cognitive behavioral therapy (CBT) and certain interventional procedures should be attempted first.

This guideline is partially in response to the rising epidemic of opioid addiction and overdose, but it is also in response to the increasing rate of patients who see positive results from these non-drug treatments: "There is high-quality evidence that exercise therapy (a prominent modality in physical therapy) for hip or knee osteoarthritis reduces pain and improves function immediately after treatment and that the improvements are sustained for at least 2-6 months." Other forms of physical and exercise therapies suggested include aerobic, aquatic, and/or resistance exercises for patients with osteoarthritis of the knee or hip.

The CDC also reports that more compassionate and appropriate care should be offered by healthcare professionals to people suffering from chronic pain, as many live with clinical, psychological and social consequences. These include issues with work productivity, restrictions in complex activities and stigma.

What do you think about the CDC's stance, and what do you think are the best practices for treating those with chronic pain? Let us know in the comments.

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Lower Impact, Higher Outcomes With Aquatics

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Future of the PTA Profession
by Dillon Stickle

ANAHEIM, CA -- Today at CSM, in a lecture titled "Transforming the Role of the PTA to Meet the Vision of the Physical Therapy Profession," speakers Jennifer Jewell, PT, DPT, Beverly Labosky, PTA, BA, Pamela Pologruto, PT, DPT, and Gina Tarud, PT, DPT, took a look at how the role of the PTA should meet the APTA's new vision: transforming society by optimizing movement to improve the human experience.

The speakers noted that the profession should anticipate the future knowledge requirements of the PTA. They looked at the historical perspective of the occupation, including the evolution of the liensure exam and the change in requirements of the PTA.

They looked at the current role of the PTA, specifically on supervision, continuing education, and the overall scope of the PT practice.

On supervision, a surprising 68% of states had PTAs under general supervision -- the lowest level of supervision offered to the PTA -- while only 10% had direct on-site supervision.

On continuing education, statistics showed that 43 states required at least 8 hours of CEUs. They presented a number of advancement opportunities to PTA graduates, but an overwhelming number of PTAs did not know of the opportunities that were out there.

The speakers then took a look at PT/PTA perspectives and found that there were specific challenges facing the field:

- Underutilization of the PTA (including the lack of education for the PT on the role of the PTA)

- Insurance company regulations

- State practice act regulations

- Delegation

- Lack of opportunities

- Productivity standards

Finally, they took a look at the next step for the PTA profession. For example, they played with the idea of tiered degree programs, like that of the nursing programs (RN, BSN, MSN, etc.) and how that could be implemented. Another would be to advance continuing education and credentialing opportunities for the PTA.

The lecture ended with a fitting quote from Walt Disney: "Around here, we don't look backwards for very long; we keep moving forward, opening new doors and doing new things because we're curious... and curiosity keeps leading us down new paths."

"Unflattening" Higher Education
by Dillon Stickle

ANAHEIM, CA -- Diane Jette, PT, DPT, DSc, FAPTA presented the thought-provoking lecture, "Unflattening," tonight for the Pauline Cerasoli Lecture. The title was named after the book Unflattening by Nick Souzanis, a novel that presents a serious inquiry into the ways humans construct knowledge. This was directly related to Jette's thoughts and ideas on higher education. She showed a video from Cosmos that showed the world, and all who inhabit it, as flat. But an apple, a three-dimensional object, came and defied the normal way of living. Jette said, "I am the apple. I am going to be the third dimension of higher education."

Jette then asked everyone to break through the two-dimensional idea of their profession and challenge the status quo of higher education.

She went on to discuss the reasons higher education is on a downhill slope; politics as usual, institutions grappling with lowering costs but saving revenue, static data which produces ill-equipped graduates, lack of student diversity, and much more.

Jette then asked a provocative question: How long will it take for increases to the price of our programs to diminish the value of entering the physical therapy profession?

At the end of her lecture, Jette asked the audience to consider these 6 suppositions:

1. It is our responsibility to address the need for diversity in the healthcare workforce and consequentially improve access to healthcare.

2. We must prepare graduates to work in a complex healthcare system in which uncertainty is the norm.

3. We need curricula reform.

4. Costs of the programs and the level of student loan debt are unsustainable.

5. Professionals have to become more efficient.

6. Work together -- accelerate learning through networked connections.

We look forward to covering more challenging lectures on the state of the physical therapy profession here at #APTACSM!

Words Mean Things
by Dillon Stickle

ANAHEIM, CA -- Language, both verbal and non-verbal, are important tools in the therapist-client relationship. In a lecture called "Words Mean Things: How Communication Impacts Clinical Results" given by Kevin Lulofs-MacPherson, PT, DPT, OCS, Larry Benz, PT, DPT, OCS, MBA, and Tim Flynn, PT, PhD, we learned the value of language and how it can affect the outcomes of a therapist's client.

The speakers went through things like verbal and non-verbal layers of communication. We learned that patient satisfacion is tied to social talk, direct eye contact, body language, physical contact, close interpersonal distance, less time on a chart, and not frowning. They said that distancing behaviors in the therapist leads to poor functional outcomes for the patient.

An interesting take was that of anxiety in the patient. If a patient is given an angry expression, it results in an avoidance tendency; however, studies show that if the patient is given an overly happy expression, the outcome is often the same as when they're given an angry expression. The speakers questioned whether PTs need to start "toning down" their approach to communicating with patients.

One of the speakers went over "thinking traps," one being the use of abstract words. The more abstract a word, the heavier the load on your brain. Another "trap" was the idea that PTs are empathetic by nature. They said that PTs actually need to learn and condition their empathy -- "it's like a muscle." It was suggested that if you do not like the word "empathy" then to think of it as curiosity.

In this session, PTs were challenged to reconsider their role in the "therapeutic alliance," which is the relationship between the healthcare professional and the client. Should they continue looking at an iPad while their client looks around, not really paying attention to the session? Or should the therapist offer the patient a look at the iPad as well, so that there is a "shared object of attention"? I think after today, most PTs would consider the latter to result in the best patient outcomes.

Empathy in the Curriculum
by Dillon Stickle

ANAHEIM, CA -- As most of you know, the APTA Combined Sections Meeting (CSM) is underway, and ADVANCE is excited to be here to cover the happenings of the nation's largest conference for physical therapy. According to the CSM website, this year's conference has brought over 10,000 professionals from all around the country to join in learning and celebrating the physical therapy profession, and to hear from veteran PTs speaking on various topics.

The first notable session was the Linda Crane Memorial Lecture, named after one of the first PTs to be certified in a specialty by the APTA. The speaker was Julie Ann Star, PT, DPT, CCS, clinical associate professor at Boston University and physical therapist at Beth Israel Deaconess Medial Center in Boston, MA. The title of her lecture was "The Science of Healing. The Art of Caring. #heartofthematter."

Star told stories of her days as a PT, and as a healthcare professional in general. She told the story of the Boston Marathon bombing, and how when push came to shove, every single healthcare professional there that day stepped up to the plate. Star asked a question to the audience; a thought-provoking question: Which way will you run? She said that the responsibility of the professional is to run toward the danger; after all, the core idea of healthcare is to help people who are sick or hurt.

Star followed these stories with an idea that maybe the curriculum of PT schools didn't involve enough learning of empathy, compassion, and communication. This was the "art" of physical therapy. She shared a shocking study that showed in the last 10 years, empathy in DPT students has dropped dramatically. She pondered: "If the art of PT is to ensure the highest standard of excellence, then we need to be intentional about it. Are we teaching this in our curriculum?"

At the end of the lecture, Star told a memory of the week after the bombing, when her friend asked, "Isn't the younger brother alive and being treated at your hospital?" After Star replied, "yes," her friend asked, "Well, you're not going to help take care of him, are you?"

 Star looked to the audience and challenged: "would you?"

 We will be covering a lot more at #APTACSM in the next couple days and are excited to see what else the conference has in store. Check in with us for more updates, and be sure to follow us on Facebook (Advance for Physical Therapy and Rehab Medicine) and Twitter (@AdvanceforPT)!

PT and OT Stand Out in 2016 ‘Best Jobs' Ranking
by Brian Ferrie

Every year, professionals, students and prospective students across the country eagerly await "The 100 Best Jobs" ranking published by U.S. News & World Report. The just-released 2016 list offers great reason for physical and occupational therapy professionals to feel proud, and for students to feel optimistic about pursuing careers in these fields. 

Among the 100 Best Jobs overall, physical therapist ranked a very impressive #14, while physical therapist assistant (#40) and physical therapist aide (#52) also represented well. The occupational therapy field enjoyed significant recognition too, with occupational therapist ranking #23, occupational therapy assistant #25, and occupational therapy aide #59. In the "Best Health Care Jobs" ranking specifically, the numbers were even more eye-catching, with physical therapist ranking #12 and occupational therapist #17.

U.S. News states, "Good jobs are those that pay well, challenge us, are a good match for our talents and skills, aren't too stressful, offer room to advance and provide a satisfying work-life balance. Even though there is no one best job that suits each of us, the 100 Best Jobs of 2016 are ranked according to their ability to offer this mix of qualities. Also, the best careers are ones that are hiring."

According to U.S. News, the U.S. Bureau of Labor Statistics projects a physical therapist job growth rate of 34 percent by 2024, with an occupational therapist growth rate of 27 percent over the same time period.

What are your thoughts about the rankings and their reflection on these rehabilitation professions? Do you believe that physical and occupational therapy offer some of the best careers in the country?

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Therapy for Parkinson's
by Dillon Stickle
The Journal of the American Medical Association (JAMA) Neurology released a study on Tuesday which suggested that the current standard of care for early-stage Parkinson's patients may be a waste of time and money. The study said that both PT and OT offer "no improvement of quality of life" and that there were no "short or medium-term benefits."

A recent article on ADVANCE for Physical Therapy and Rehab Medicine claimed that, "Patients today are far more educated on the disease, have lots of questions, and know that physical therapy combined with prescribed exercises will impact their quality of life moving forward. Potentially, it could even slow the progression of the disease."

We shared the study with our Facebook fans via a Yahoo News article, and there seemed to be a united consensus: the study was misleading or misrepresentative of the role PT plays in the treatment of a patient with Parkinson's disease.

Here are some things PTs had to say:

"Treating injuries is not the main focus of any plan of care from a skilled PT that is treating someone with PD."

"That seems at odds with the multiple studies that have clearly shown how exercise and therapy benefit Parkinson's patients short- and long-term."

"If there was no progress or benefits for PD patients in this study, than the PTs may need a review of how to write functional goals."

"It depends on what the PT focuses on. Doing only strengthening exercises won't help. Focusing on balance, movement strategies, etc. does help. But, these have to be incorporated into daily life by the patient and family/caregiver."

Some fans pointed out the fact that balance exercises and range of motion were not part of the study, which many PTs consider their role to improve in a patient with Parkinson's. Some even argued the study was skewed because of biased healthcare providers.

What are your thoughts on the role of PT in cases of patients with Parkinson's? Let us know in the comments.

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Can Helmetless Drills Decrease Football Head Impacts?
by Brian Ferrie

The National Athletic Trainers' Association (NATA), Dallas, issued an interesting press release Dec. 18 related to the hot-button issue of head impacts in football. The release stated:

"Head impacts in football players are directly associated with brain and spine injury and have been suggested to be associated with chronic injuries, making this a topic of continued national concern. To reduce the risk of head-impact injury, researchers and others have sought ways to improve helmet technology, reduce contact during practices, and alter game rules."

A new study, "Early Results of a Helmetless-Tackling Intervention to Decrease Head Impacts in Football Players," published in the Journal of Athletic Training investigated the effectiveness of helmetless tackling to reduce head-impact exposure in an NCAA Division I football program.

"Given proper training, education and instruction, college football players can safely perform supervised tackling and blocking drills in practice without helmets," said Erik E. Swartz, PhD, ATC, FNATA, lead author of the study and professor and chair, Department of Kinesiology, University of New Hampshire. "This intervention also eliminates a false sense of security a player may feel when wearing a helmet. Younger players with less experience may require modifications to this intervention to realize a positive effect. While more research is needed, our results do show a reduction in head impacts during our one season of testing."

The results stem from the first year of a two-year study focusing on 50 NCAA Division I football players at the University of New Hampshire who were assigned to an intervention or control group. The intervention group participated in 5-minute tackling drills without their helmets and shoulder pads. Drills occurred twice per week during preseason practices and once per week throughout the competitive season. Meanwhile, the control group performed noncontact football skills with no change to their routine. All athletes were provided head-impact patch sensors worn on the skin and new helmets. At the end of the season, the intervention group experienced a 28-percent reduction in head impacts during practices and games than the control group.

"These findings elucidate the risk-compensation phenomenon and may help explain the behavior of spearing and the rise in catastrophic neck and head injuries that followed," the study authors noted. "A football helmet is designed to protect players from traumatic head injury, but also enables them to initiate and sustain impacts because of the protection it affords. While improving protective equipment in and of itself will not resolve the risk of concussion and spine injury in football, the solution may be found in behavior modification."

What are your thoughts about this study and the merits of helmetless drills to help reduce head impacts in football?

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An Unpopular Stance on POPTS
by Jon Bassett

This guest blog was written by Cary Edgar, JD, president of PT Management Support Systems.

In 2011, I published an editorial in ADVANCE explaining why the APTA's decades-long campaign against physician-owned physical therapy services (POPTS) is unfounded, misguided, and ultimately self-destructive.1 The APTA has continued its campaign against POPTS and continued to cite outdated studies as support for its argument that POPTS results in overutilization and excessive costs.2 These studies were conducted over 20 years ago, before the enactment of the Stark rules. Furthermore, these studies used questionable research methods and arrived at dubious conclusions.3

In the meantime, two more objective, comprehensive and rigorous studies have been published showing that PT provided within a physician practice actually results in lower utilization and costs than therapy provided in private practices. To date, the APTA has failed to mention either of these studies, despite the fact that it partially funded one of these studies and the other study was conducted by the GAO.

In addition, the APTA's sister organization, The Foundation for Physical Therapy, sponsored another recently published study finding that physician groups see PT patients for fewer visits per episode, units per episode and units per visit than private PT practices.4 And although the APTA announced the original grant for this study,5 it has failed to publish or even refer to the results of this study.

Beattie Study

In January 2013, the Journal of Occupational Rehabilitation published a study entitled "Differences among Health Care Settings in Utilization and Type of Physical Rehabilitation Administered to Patients Receiving Workers Compensation for Musculoskeletal Disorders."6 This was a study of workers compensation claims during 2009-2011 covering over 70,000 patients. This study found that physician-based PT averaged about 10.5 visits and 42.7 units per patient while (a) private PT practices averaged over 12 visits and 51 units per patient-which represents 16.3% more visits and 22.2% more units per patient than physician-based PT, and (b) corporate PT clinics averaged over 13 visits and close to 67 units per patient -- which represents 25% more visits and 56.3% more units than physician-based therapy.

This study was partially funded by the APTA. However, while the APTA continues to cite 1992 studies to supports its claims of physician over utilization, it makes no mention of this comprehensive study published in 2013 finding exactly the opposite.

United States General Accounting Office

At the request of Congress, the U.S. General Accounting Office conducted a study of Medicare data from 2004-2010 to determine whether physician-owned therapy resulted in higher costs than PT in other settings. The GAO compared self-referred (physician-owned) PT to non-self-referred PT and found that:

  • (a) From 2004 through 2010, the number of PT services (procedures) per 1,000 self-referred patients was generally flat while the number of services per 1,000 non-self-referred patients grew by 41%.
  • (b) From 2004 through 2010, total Medicare expenditures for self-referred PT increased by 10% while expenditures for non-self-referred services increased by 57%.
  • (c) Self-referring physicians, on average, referred fewer PT services per beneficiary than non-self-referring providers.

The GAO concluded that:

Our review indicates that PT service use and expenditures grew considerably from 2004 to 2010, despite a slight decrease in the total number of FFS beneficiaries over this period. The primary driver of this growth was growth in non-self-referred services. These results differ from our prior work on self-referral of other Medicare services-namely, advanced imaging, anatomic pathology, and intensity-modulated radiation therapy-in which we reported that self-referred services and expenditures grew faster than non-self-referred services and expenditures. One potential reason for this difference is that non-self-referred PT services can be performed by providers who can directly influence the amount, duration, and frequency of PT services through the written plan of care required by Medicare. In contrast, non-self-referred services we examined for our prior work tend to be performed by providers who have more limited ability to generate additional services or referrals; for example, radiologists generally do not have the discretion to order more imaging services or more intense imaging procedures.7

In other words, the GAO concluded that therapists in private practice largely influence the amount of PT delivered and have used that influence to increase PT visits, procedures and costs at a much higher rate than physicians and therapists providing PT within a physician group.

Mitchell Study

The APTA's foundation, The Foundation for Physical Therapy, sponsored a recent study of low back pain patients covered by Blue Cross Blue Shield of Texas.8 This study compared PT utilization rates between self-referred (physician-based) PT and non-self-referred PT. Like the GAO study, it found that therapists in private practice see patients for more services (units) per episode than therapists working within physician groups. However, the Mitchell Study actually went further and found that therapists in private practice average more visits per episode and units per visit than therapists working within physician groups. More specifically, the Mitchell Study found that PT provided within physician groups averaged 27% fewer visits per episode, 34% fewer units per episode, and 9% fewer units per visit.9 So, PT care within physician groups was actually less expensive per episode than care provided by private PT practices.

In an attempt to justify the additional services delivered by private practices, Mitchell reviewed the mix of procedures and suggested that private PT practices delivered higher quality of care because the percentage of active treatments (timed codes) were higher than those billed by therapists working with within physician groups. More specifically, Mitchell stated that:

Electrical stimulation (a passive treatment) accounted for almost 9% of the physical therapy services rendered during self-referring episodes, whereas use of this modality among non-self-referring episodes was negligible (1.4% of all physical therapy services). The 7.4 percentage point difference was highly significant.10

This conclusion is based on a count of attended electrical stimulation procedures billed under 97032. Mitchell fails to share data for or even refer to the much more common unattended electrical stimulation code billed under 97014. This failure to account for one of the most common modalities and instead base conclusions on a relatively uncommon modality begs the question of whether any practicing physical therapist actually reviewed the findings and conclusions.

The Beattie and GAO studies are rigorous and broad-based studies that clearly demonstrate that physician groups actually provide PT at lower utilization levels and costs than private PT practices. Likewise, the Mitchell Study, which was no doubt trying to find support for the APTA's assertion that physicians over utilize therapy, actually found fewer visits per episode, units per episode and units per visit in physician groups as compared to private PT practices. The APTA's continued claim that physicians are "referring for profit" is simply not supported by the evidence and disparages physicians, therapists and assistants who are delivering exemplary care.

While the APTA continues to support exclusive physical therapist ownership and operation of physical therapy services,11 the U.S. healthcare system and the vast majority of other healthcare providers are moving towards large integrated healthcare delivery systems. Congress, CMS and MedPAC have all adopted policies encouraging integrated delivery systems to both provide better quality care and control healthcare costs. These large integrated delivery systems include physicians, physical therapists, and other healthcare providers who work as a team to coordinate care so that each patient is provided the most appropriate care at the lowest cost possible without the potential impediments raised when care is provided by economically independent providers.12

The APTA may argue that therapists in independent PT practices are as capable of coordinating patient care as therapists who are members of integrated delivery systems. However, a number of factors favor integrated delivery systems, including the use of a single electronic health record system, more contact with other providers to allow for better coordination of care, and better coordination of payment mechanisms that facilitate cost savings.

The APTA's admirable vision statement includes the following principles:

The physical therapy profession will offer creative and proactive solutions to enhance health services delivery and to increase the value of physical therapy to society. Innovation will occur in many settings and dimensions, including health care delivery models, practice patterns, education, research, and the development of patient/client-centered procedures and devices and new technology applications. New models of research and enhanced approaches to the translation of evidence will more expediently put these discoveries and other new information into the hands and minds of clinicians and educators.13

The APTA and its state chapters have devoted a tremendous amount of time, energy and money in their long campaign against physician-owned therapy (and therapists and assistants who are members of physician groups) with very little to show for their efforts other than alienation of a large portion of the physical therapy profession, physicians and other providers. The APTA should follow the principles in its vision statement, recognize that exemplary care is being delivered through physician groups on a collaborative and cost-effective basis, acknowledge and agree that therapy can be effectively provided in a variety of settings, and reverse its misguided policy against providing therapy within physician groups.

References can be accessed here.

Cary Edgar is president of PT Management Support Systems, Phoenix, Ariz. Contact: pt-management.com

PT and PTA Student ‘Flash Action' Focuses on Congress
by Brian Ferrie

The American Physical Therapy Association (APTA), Alexandria, Va., issued an important news release on Nov. 9 related to loan repayment for new graduate physical therapists.

The release stated: "In a ‘Flash Action' effort led by students from PT and PTA education programs, supporters of legislation that would allow PTs to participate in the National Health Service Corps (NHSC) flooded Congress with more than 18,000 letters sent to Washington, DC, during an intensive 2-day drive on November 4-5.

Inclusion in the NHSC would increase access to PTs in rural and underserved areas, in part by allowing PTs to participate in the NHSC and its Student Loan Repayment Program. That program repays up to $50,000 in outstanding student loans to certain healthcare professionals who agree to work for at least two years in a designated Health Professional Shortage Area.

The campaign not only succeeded in making the voice of physical therapy heard on Capitol Hill, but also created ripples across social media. The #PTAdvocacy hashtag was used 600 times on Twitter during the days of the flash action, and the campaign's top Facebook post reached 15,826 people."

Are you interested in participating in the National Health Service Corps? What do you think about seeing this kind of PT advocacy in action?

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Proving the Value of Physical Therapy
by Brian Ferrie

This guest blog post was written by Jerry Henderson, PT, vice president of clinical community at Clinicient in Portland, Ore.

I personally believe that our profession is an excellent value. That is, our efforts provide a great benefit for the cost. Unfortunately, regardless of the conviction of my beliefs, we have an obligation to prove it to payers and, more importantly, to the consumer. Believing that we provide a great value is easy... proving it is hard.

Value is often defined as outcomes divided by costs. But measuring outcomes and, to a lesser extent, costs is difficult. Of course if we can't measure costs or outcomes, we can't prove our value.

Measuring Outcomes

Nearly every physical therapist I've ever known will tell me they provide superior outcomes. This is, of course, absurd. Not everyone is superior. I believe that many of my colleagues provide great care. But, of course, some provide only average care and there are even a small number who provide (gasp!) substandard care.

Jerry Henderson, PT

Let's compare measuring physical therapy effectiveness to effectiveness for medical problems:

For certain cancers, a crude measurement of effectiveness is based on mortality. Just studying what was done for the patients who lived compared to the ones who died provides great information on outcomes.

Type 2 diabetes is another example. Manipulating diet and drugs while monitoring lab values and controlling for demographic variables and lifestyle provides an amazing amount of useful information on morbidity.

Rehabilitation professionals do not (except in the most extreme cases) have a role in extending life. We don't treat diseases. We help our patients improve function. The absence of death is very easy to measure. The absence or improvement of disease is generally measurable.

In contrast, improvement in function can be difficult to measure. Medicare's attempt to somehow measure function is a case in point. In the absence of universally accepted objective standards for measuring functional improvement, Medicare instituted an extremely subjective process of classifying patients and rating their impairment. The current state of the art in measuring functional improvement is based on patient questionnaires, which are rough subjective indicators of functional status, not objective measurements of function.

In addition, understanding which interventions were provided in rehabilitation specialties is difficult. In medicine, it is pretty clear which drugs were prescribed. In rehabilitation specialties, it is not at all clear which procedures were performed, since there is no standard nomenclature across the professions for therapeutic exercise and manual therapy, and the procedure codes that we use for billing do little to describe what was actually done.

Measuring Cost

Surprisingly, measuring cost is also problematic, simply because healthcare records are stored in multiple, non-integrated databases. Take the example of a patient who has an elective orthopedic surgery for a knee replacement. That patient may have been seen by a family doctor for a number of years, and a physical therapist for a period of time prior to referral to an orthopedic surgeon.

Chances are good that the cost data for the treatment of that condition has already been stored in at least three different data repositories, and that's before the patient is hospitalized for surgery. On top of all that, there is nothing preventing the patient from changing insurance companies, introducing yet another data silo.

Theoretically, a payer may be able to correlate all of that information from the outpatient and inpatient providers and get an accurate idea of the cost, but there are many reasons to believe it is doubtful.

Measuring Overall Value

This article in the Harvard Business Review, "Getting Real About Healthcare Value," makes the point that comparing the true value of improvements in health status is extremely difficult. For one thing, the potential side benefits of effective treatment are not taken into account.

To illustrate with an example, many studies show that physical therapy is effective in treating and preventing chronic low-back pain, and that it saves many other immediate costs including unnecessary imaging and invasive procedures. One can hypothesize that many other conditions are potentially improved or prevented by effective treatment for that patient population, including obesity, arthritis and heart disease, creating a stunning "multiplier effect" that results in decreased healthcare costs in years to come.

We have a huge opportunity to improve on the value proposition of our profession, but we need to start with using integrated information systems that help guide our clinical decision-making, standardize our terminology, improve outcome measurements, and track our costs.

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APTA Takes Aim at SNF Productivity Controversy
by Brian Ferrie

The American Physical Therapy Association (APTA), Alexandria, Va., issued an Oct. 8 press release detailing how the organization has spoken out in The New York Times (NYT). This initiative was precipitated by recent reports that skilled nursing facilities (SNFs) are taking advantage of Medicare billing policies. The APTA states that these allegations underscore the need to replace volume-based payment systems with systems tied to value.

In a letter to the editor published today, APTA President Sharon L. Dunn, PT, PhD, OCS, responded to a September 30 NYT article titled, "Nursing Homes Bill for More Therapy Than Patients Need, US Says." That story focused on a report from the Office of the Inspector General (OIG) of the US Department of Health and Human Services alleging that Medicare payments have "greatly exceeded SNF costs for therapy for a decade."

According to the APTA press release, this OIG report and related media coverage are directly related to the pressures being placed on physical therapists, physical therapist assistants and other providers to meet productivity demands that can sometimes run counter to actual treatment needed.

"The provision of physical therapy services should be driven by patient need and the clinical judgment of the licensed physical therapist," Dunn writes in her letter. "Productivity goals that drive services toward economic incentives continue to be an issue that policymakers and professional associations have a joint responsibility to meet."

Much of the criticism of SNFs is centered on the use of ultrahigh therapy hours in billing practices, the APTA press release continued. CMS estimates this tactic provides facilities with an average of $66 a day in payments over costs. In the APTA letter to NYT, Dunn also describes APTA's collaborative efforts to address volume-based vs. value-based care, and how the association's "Integrity in Practice" campaign aims to provide PTs and PTAs with resources to support care based on patient need and clinical judgment.

"We are committed to making sure that the correct incentives are invoked in care delivery, in a manner that maintains our patients' trust," the letter states.

What are your thoughts about these developments and the issue of unethical billing practices? Share your comments below!

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Tai Chi Improves Physical Function
by Dillon Stickle
Yoga and Pilates are both well known in the therapy world and are often used as a complementary activity for patients with chronic pain and long-term conditions. Not many people, however, use Tai Chi as an example of such exercises - but maybe they should start.

The British Journal of Sports and Medicine published a systematic review on the effects of Tai Chi on four specific chronic conditions: osteoarthritis, heart failure, chronic obstructive pulmonary disease (COPD), and breast cancer. The study was put together by a team of researchers in the University of British Columbia's Physical Therapy department, located in Vancouver. The idea behind the study was to see if Tai Chi would be a successful activity for easing the symptoms and quality of life for people with one or more of these conditions.

The results were as follows: "Meta-analyses showed that Tai Chi improved or showed a tendency to improve physical performance outcomes, including 6-min walking distance (6MWD) and knee extensor strength, in most or all four chronic conditions. Tai Chi also improved disease-specific symptoms of pain and stiffness in OA [osteoarthritis]."

They concluded that Tai Chi could be used as a safe form of exercise for people with one or multiple chronic conditions, and showed a tendency to improve physical performance in those with said conditions.

PTs, have you ever incorporated Tai Chi for patients with chronic conditions? If so, how do they compare to activities such as yoga or Pilates? If you haven't, would you ever consider using Tai Chi in your practice? Share with us in the comments!

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